Complaint Investigation Report

A record of R1s weight between July 2023 and July 2024 shows R1s weight gradually fluctuates throughout the year. R1 saw their physician regularly, there was no documented concern of malnourishment. Marin County Sheriff report determined facility staff did not willfully cause R1 to be endangered. The allegation of neglect/lack of supervision resulting in severe malnutrition is UNSUBSTANTIATED.

Regarding the allegation of neglect/lack of supervision resulting in unexplained pressure injuries, facility staff observed R1 to have a pressure wound on July 23, 2024, R1s physician was notified and an appointment was made for August 2, 2024. On August 2, 2024, R1 was diagnosed with two staged two pressure injury on their coccyx and a stage one pressure injury on their elbow. Between July 23 rd and August 2 nd staff were applying medical honey to R1s pressure injuries. A review of resident notes did not indicate the pressure injuries worsened during this time. Facility staff interviewed indicated R1 was not bedbound, was able to transfer and ambulate. R1 would frequently come out into the living room. When R1 eventually required a wheelchair, R1 would transfer from the wheelchair to the couch or chair. Facility notes indicate R1 was to be repositioned regularly, facility staff interviewed stated they do not keep a log or repositioning schedule. The allegation of neglect/lack of supervision resulting in unexplained pressure injures is UNSUBSTANTIATED.

Regarding the allegation of staff did not seek timely medical care, facility staff interviewed indicated that R1 had a decreased appetite but never stopped eating. R1s 2024/2025 Individual Service Plan indicates “R1 historically has fragile health…” During the August 2, 2024 visit with R1s physician, R1s physician ordered a wound care consult and cushion for seated support. On August 11, 2024 R1s health declined further and facility staff transported R1 to the ER. R1 was admitted to a local hospital. The Department attempted to interview R1s physicians, to date neither of the physicians have responded. The allegation of staff failed to seek timely medical care is UNSUBSTANTIATED.

Findings of UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.